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2 Presented by Patrick Romano, MD, MPH Professor of Medicine and PediatricsUniversity of California DavisOn behalf of the Agency for Healthcare Research and QualitySeptember 28, 2007

3 Retinopathy of prematurityRetinopathy of prematurity (ROP):A vascular proliferative disorder of the retina in premature infantsCommon cause of childhood blindness: children annuallySequelae affect another 2100: myopia, strabismus, retinal detachmentIncidence and severity decrease with increasing gestational age and birthweightIncidence of all stages of ROP >50% in preterm infants with birthweight < 1250 gIncidence of stage 3 or greater ROP is 6% in preterm infants with birthweight <1250 g

4 ROP developmental biologyBefore 16 weeks, the embryonic retina has no vessels. Blood flow is supplied by vessels that are usually reabsorbed by 34 weeks.Vascularization of retina begins between weeks, and is usually complete by 36 weeks (nasal retina) and 40 weeks (temporal retina)ROP is thought to develop when new vessels are injured, disrupting normal angiogenesis.Risk factors include prematurity, low birth weight, and severe respiratory disease with/without hyperoxia

5 ROP staging Stages 0: Immature retina without vascular changes1: Flat line demarcates the vascular and avascular areas2: Fibrous tissue protrudes into the vitreous between the vascular and avascular retina3: New blood vessels and fibrous tissue along ridge or extending into the vitreous4: Partial retinal detachment5: Total retinal detachment

8 ROP codingCurrent coding lumps together all stages and acute/cicatricial disease into one codeRetrolental fibroplasiaProviding more granularity allows:Separation between cicatricial (chronic) disease and acute diseaseSeparation between minor ROP (requiring observation but no treatment) and severe ROP (requiring treatment)

9 ROP coding rationaleROP rates are currently tracked by several organizationsChild Healthcare Corporation of AmericaNational Perinatal Information CenterOverall incidence has been stable over the past 20 years, but incidence varies widely across NICUs, and infants delivered at subspecialty perinatal centers have lower rates of ROP than those born elsewhereAHRQ Clinical panel suggested more granularity in coding would aid in research and surveillanceBest practices are unknown, but careful oxygen management to avoid hyperoxia and repeated episodes of hypoxia-hyperoxia shows promiseRCT of infants with prethreshold disease (p=0.035)

12 NEC radiographyFIGURE A–D: Girl with necrotizing enterocolitis. Frontal (A) and lateral (B) radiographs at 2 days of age show dilation of the small and large intestine with extensive intramural gas. Frontal radiograph at 6 days (C) shows generalized small bowel distention and quite extensive gas within the portal veins. There is atelectasis of the right lower lobe. Two days later (D), perforation has occurred, with a large pneumoperitoneum. Gas persists within the portal vein branches within the liver. Aeration of the lungs has deteriorated. (Reprinted with permission from, Elzouki AY, Harfi HA, Nazer H. Textbook of clinical pediatrics. Philadelphia: Lippincott Williams & Wilkins, 2000:247.)

13 NEC treatment Treatment includes supportive careCardiovascular and respiratory support if requiredMay include discontinuation of feedings, GI decompression with nasogastric suction, fluid replacement, parenteral nutrition, antibioticsSurgical intervention may be required for abdominal mass, ascites/peritonitis, or intestinal obstruction. May include intestinal resection or peritoneal drainage.

14 NEC coding Current coding lumps together all NEC into one codeNecrotizing enterocolitis in fetus or newbornProviding more granularity allows:Separation between NEC, mild NEC requiring medical therapy (e.g., pneumatosis), and severe NEC that often requires surgical therapy (e.g., perforation)Diagnosis of NEC may vary, especially in early stages. Findings of pneumatosis and perforation provide standards for coding.

15 NEC coding rationaleNEC rates are currently tracked by several organizationsChild Healthcare Corporation of AmericaNational Perinatal Information CenterIncidence varies across NICUs, and cases occur in clusters suggesting a transmissible agent.AHRQ Clinical panel suggested more granularity would aid in research and surveillanceBest practices are unknown, but several interventions show promiseAntenatal corticosteroids reduce NEC by 54% (8 RCTs)Feeding donor human milk (versus formula) reduces NEC by 66% to 75% (4 RCTs)Proper velocity of feeding volume advancement is controversialImplementation of any standardized feeding regimen has been associated with an 87% reduction in the risk of NEC (6 quasi-experimental studies)

16 Disruption of Operative WoundFailure of operative wound to heal results in full or partial dehiscence (separation)Disruption can be superficial or extend into the fascia or muscleAnatomy of abdominal wall

19 Disruption: preventionProper stitching and surgical techniqueUse of appropriate suture material for tissuePrevention of surgical site infectionAccounting for special situations (e.g. obesity)

20 Disruption: coding History of codeFY 2003: 998.3, “Disruption of operation wound” split into two codes998.31: Disruption of internal operation wound998.32: Disruption of external operation woundPhysicians tend to document the tissues and/or layers involved, rather than using the terms “internal” and “external”“Disruption of operation wound NOS” is coded to (“external”)